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Nursing informatics, a branch of health informatics, has been defined by Judith Rae Graves and Sheila Corcoran as "a combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care". [3]
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
Healthy Work Environments Best Practice Guidelines In July 2003, RNAO commenced the development of evidence-based best practice guidelines aimed at creating a healthy work environment for nurses. This was achieved with funding from the Ontario Ministry of Health and Long-Term Care, working in partnership with Health Canada's Office of Nursing ...
Direct medical direction, often called on-line medical direction, is when care is rendered under direct orders of the base station physician, usually over the radio or telephone. The other is indirect medical direction, or off-line medical direction, which includes the development of a set of written medical guidelines , or standing orders.
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Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]